Craniofacial Pain of Cardiac Origin
Twenty years ago, health professions were not aware that certain oral bacteria, if permitted entrance into the gingival blood vessels, could cause some strokes and heart attacks. Recent research has validated the opinion that “dental” structures and associated symptoms are actually an integral part of human medicine, and that physicians and dentists shared some serious responsibilities that were, until as of late, generally unrecognized.
Dr. George Goodheart, developer of ‘Applied Kinesiology’ in the 1960’s, once commented that the temporomandibular joints (TMJ), dentition (teeth), and the trigeminal nerve were among the most important survival structures of the human body, and that there was a specific reason that the trigeminal nerve was the largest (not longest) cranial nerve in the body. Researchers have postulated that a significant portion of the brain is devoted to the reception, processing, and interpretation of trigeminal autonomic, sensory, and motor information. That theory is now supported by most neurobiologists who estimate that up to 70% of the brain is devoted to the trigeminal nerve.1 Hopefully, this article will serve to highlight this important clinical area that, at one time or another, may affect up to 40% of the US population with a variety of conditions. The general term TMD will not be used as a diagnostic category in this article simply because is not a diagnosis. In this article, I will describe two differing cardiac cases: the first being a more classic cardiac patient with very typical symptoms and the second case being one with mostly craniofacial pain symptoms and helps highlight the differences between male and female presentations of cardiac conditions.
Kreiner and Okeson2 reported symptoms of toothache of cardiac origin in 1999, and Tzukert3 reported orofacial pain of cardiac origin in 1981 in the Journal of Oral Surgery, Oral Medicine and Oral Pathology. Friction4 reported a myofacial pain syndrome of the head and neck of cardiac origin, and Biagini5 reported on dental clinical characteristics of anginal pain in Functional Neurology. Ana Franco6 reported, in 2006, a case of facial pain of cardiac origin in the Sao Paulo Medical Journal. And Kreiner and Okeson7 also published an article in 2007 titled ‘Craniofacial Pain as the Sole Symptom of Cardiac Ischemia: A prospective multicenter study.’
Perhaps the most recent publication on this subject appeared as a guest editorial by Dr. Anika Isberg in the January 2009 issue of Cranio Journal and titled “The Life Threatening TMD.”8 Her editorial correlates the signs and symptoms of craniofacial pain as a result of cardiac ischemia or acute myocardial infarction. She used the term “TMD” in her editorial title to highlight the risk of a missed diagnosis or a misdiagnosis. This is particularly true when the patient is directed to the dentist for TMJ or facial pain-related symptoms and then treated for some lengthy period of time for a TMJ disorder. In this scenario, there is the potential to miss the timely referral and treatment necessary for a life-threatening cardiac condition.
It is possible for a patient to suffer both a TMJ disorder and cardiac ischemia at the same time. If the most dominant pain symptom is TMJ, facial pain, or tooth pain, the patient may likely seek a dentist rather than the emergency room. That mistake could be fatal as this paper highlights in the discussion of Case 2. In fact, in Case 2, the ER physician who saw the patient did refer the patient to a dentist for a facial pain evaluation because the facial pain suffered was the most intense and excruciating complaint. The loudest complaint drove the referral choice and could happen to any physician. As to the reason for cardiac-induced referred pain to the craniofacial region, there is no clear neuroanatomic link but it is interesting to note that the stomodeum or mouth pit, at the fourth or fifth week of embryologic development, is found as a depression between the brain and the pericardium. Perhaps future research will be able to offer additional insight that may explain the role of the trigeminal nerve and the heart.
Kreiner, Okeson, and team provided several important criteria in the description and prevalence of craniofacial pain in cardiac patients2:
1. Craniofacial pain as the sole symptom of cardia ischemia or acute myocardial infarction is almost 10 times more common in females than in males.
2. Females are more likely to have atypical ECG results.
3. Referred pain from cardiac events can be bilateral.9
4. Craniofacial pain is triggered by physical stress such as walking up stairs. The pain generated is of short duration and is alleviated by rest and likely the result of cardiac ischemia. If the pain persists then it may be acute myocardial infarction (AMI).
5. Craniofacial pain symptoms mixed with the classic cardiac symptoms are found in about 40% of female patients.
6. In about 6% of cardiac patients, craniofacial pain symptoms are the sole complaints. Those symptoms include pain felt at the:
b. left mandible
c. right mandible
e. temporomandibular joints
7. In the absence of chest pain, the craniofacial region is the most prevalent place for the patient to experience referred pain from cardia ischemia or acute myocardial infarction. In referred pain from cardiac events, the craniofacial region is three times more likely to be painful than the left arm; four times more likely to be painful than the left arm; and four times more likely to be painful than the stomach and back.
Isberg also stated that one in three craniofacial pain patients—with no chest pain during cardiac ischemia—may develop AMI and are at risk of death.8
Because of the gender differences between men and women having cardiac ischemia—and the fact that women present with craniofacial pain symptoms much more often than men—it is very important for the clinician to consider the “atypical” gender symptoms that can confuse the clinical picture of a patient who may have a cardiac condition.
In late December 2008, a 57-year- old male patient called. Three days earlier he was awakened about 3 am with a feeling of intense indigestion and then awful chest pressure. In describing the episode, he said that it felt like someone was sitting on his chest and also as if someone had their hand in his chest and was squeezing his heart. This lasted for about 20 minutes. At the same time, he experienced extreme cramping of his hands and fingers. He actually got up and sat on his hands and fingers to try to prevent the cramping from bending his hands and fingers. This symptom lasted for a couple of hours. Other immediate symptoms included the feeling that his entire body was numb as if he had on a full body glove. The numbness felt much like how the skin of your lower lip and chin would feel after a dental local anesthetic injection to numb the lower teeth for dental care. This symptom of whole body numbness lasted for two hours following the heart attack.